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GAO report: Provider Medicare appeals still in logjam

June 10, 2016
by Pamela Tabar, Editor-in-Chief
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Despite efforts to streamline the Medicare appeals process, the backlog of appeals cases “shows no signs of abating,” notes a new report from the Government Accountability Office (GAO).

Wait times for appeal decisions have been on the rise since 2009, but the number of wait-days jumped dramatically in 2014 to more than 400 days and has doubled to nearly 820 days in just the past two years. Cases that come before an Administrative Law Judge (ALJ) are required to be decided within 90 days, yet the average timeframe is two years.

Since 2014, the Department of Health and Human Services has tried several coping methods, including offering incentives for earlier settlements, adding resources and personnel, and sending cases appealing amounts less than $1,500 to other attorneys instead of an ALJ. The agency even put a temporary hold on new recovery audits for part of 2014, hoping the appeals system could lessen the overload. New initiatives include an electronic case management system—starting in August, appeals can be filed online.

Yet the attempts to correct the pileups have not produced much relief so far, the GAO report says. That means facilities that file an appeal should be prepared to wait—a long time.

“The voices of too many patients, providers and states are going unheard because the gears of the Medicare audit and appeals system have ground to a halt,” says Sen. Ron Wyden, D-Ore., who is backing a new bill to address the issue.

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